Trauma or Not? Dr. Eng on Mental Health and PTSD

What is your opinion about televisits with a counselor, psychologist, or psychiatrist? Assuming some visits can occur via televisit, how often should the individual be seen in person to accurately assess their status?

Answer:

From the data perspective, we know that telehealth is a great option, and it reaches a lot of individuals more frequently. I have not seen any data to refute that it is less effective than when you see them in person. Telehealth has been shown to be an effective modality for delivering care.

Question:

If someone has a preexisting diagnosis of PTSD for unrelated issues (e.g., military service) but had undergone treatment and was stable and functioning well, then has a new Trauma A event, how do you differentiate major cause, even with first responders?

Answer:

We are going to be asking about their time served and employment history. If it is OIF, OND, OEF individuals, we are going to be asking about those tours. We are going to be asking about when they returned. How was their demeanor? Once they were discharged, did they feel they were able to get back to civilian lifestyle? Not all military personnel that are deployed to conflicted areas are going to meet criteria for PTSD. It is not one-to-one, but it certainly does raise the risk. If they readjusted nicely and then transitioned into law enforcement or other first responder type positions, and an incident occurred, then it is unlikely that any of their background from their military life is impacting them now to the degree of a clinical diagnosis.

Question:

What is the timeline to reach a medically stationary status for PTSD and adjustment disorder? We have some claimants that have been off work for up to 3 years and are still not medically stationary.

Answer:

For PTSD: It depends on the level of trauma and the confounding factors. From the literature standpoint, you could hypothetically have somebody run through EMDR or cognitive processing therapy several times in the protocols. It takes about 14 to 16 weeks to complete the entire protocol. The idea is that you have a patient who could still be clinical at the end of the protocol, but their symptoms have been reduced tremendously. You then know that you are working on the right path. You could do that same protocol over again, working on another aspect of the trauma or continuing that same work.

For Adjustment Disorder: Typically, there is a finite line. It should not last more than three months. If you see in the record that they are still clinical, or still claiming to be clinical, then there is more likely than not another diagnosis that has emerged that is not being effectively treated.

Question:

How often do you see PTSD misdiagnosed by a primary care provider? Do claimants have to meet all A, B, C, D, etc., to meet PTSD? Do you feel that most providers have a strong understanding of the criterion?

Answer:

This is why neuropsychologists, by and large, are diagnosticians. We work through a lot of elements that other professions in the medical field do not have the criteria for. A PTSD ICD-10 code should not be utilized without doing other due diligence just because somebody said they have trauma. The patient has to meet criterion A, B, C, D, E, F, and G. If they meet some, but not all, then they do not meet the diagnostic criterion for PTSD.

You might have a trauma-related disorder, but it is not necessarily PTSD. Occupational medicine tends to go through all the criteria and do their due diligence. If the PCP is extremely busy and has limited appointment times, they are more likely than not putting something in the chart that may or may not be accurate to the level or extent of a neuropsychologist. Alternatively, if a provider is concerned about the diagnosis of PTSD, then they can refer out for an evaluation to verify the existence of this condition.

Question:

Is it difficult to confirm a diagnosis based mostly on subjective complaints reported to a mental health professional? Why does one event or incident cause one person stress/anxiety while it may not affect someone else?

Answer:

It is important to determine if there are clear criteria of a traumatic event. Do they meet the criteria for PTSD? I will also ask the patient to explain to me in their own words what is going on in treatment. “Walk me through the events.” We try not to ask leading questions, just open-ended questions. “Can you tell me about the incident at hand?” I ask them what they have been doing in between sessions. All trauma treatments have a lot of work in between sessions. It is like asking somebody to lose weight, but they are only going to the gym once every other week.

We are delineating discrepancies that we are seeing from the record. Usually, there is some sort of paper trail of the person who came in with abrasions or bruises, etc., related to the incident. If this is based on an assault and there is no medical data to support that, that obviously makes it a lot harder. For example, a person is claiming that they got punched in the face, but they do not have any bruises. We are also looking for embedded and overt validity measures. Is their report generally valid or is their report over-exaggerated? We can see these in the multiple testing measures that we administer.

Question:

What is the percentage of mental health claims that meet all the criterion and become compensable?

Answer:

About 6–7% of mental health claims for trauma meet all the criterion and are compensable. This speaks to how rare this diagnosis is from a base-rate perspective. No one is refuting the fact that somebody can have a criterion A event. But again, this is about sustainability of the symptoms, and all categories are quite low to have that persist. Of course, you are going to have first responders or veterans that come back from active duty who are at a higher risk than the normal population.

Dr. Megan Eng, Ph.D., is a clinical neuropsychologist specializing in adult neuropsychological evaluations. She evaluates cognitive skills such as memory, problem-solving, spatial integration, and language, along with neurobehavioral and mental health functioning, including depression, anxiety, and PTSD. Dr. Eng holds an APA-accredited neuropsychology fellowship from the VA Long Beach Healthcare System. 

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A Previous "Ask the Doctor" Response
In our previous "Ask the Doctor" blog, Dr. Cooper explains how standardized assessments help inform treatment and accommodation recommendations for workers.